Arizona Priority Care (AZPC) Form

Prior Authorization Fax: 480-499-8798 Prior Authorization Phone: 480-499-8720 Prior Authorization Request Form: https://azprioritycare.com/for-providers/prior- authorization/ PROCEDURES & SERVICES THAT DO NOT REQUIRE PRIOR AUTHORIZATION  This grid applies ONLY to providers who participate with Arizona Priority Care, and services are rendered in-office, at home, or in a free-standing facility.  Prior Authorization is ALWAYS a requirement for providers who are NOT in our network.  Prior Authorization is ALWAYS a requirement for elective inpatient and outpatient admissions.  Benefits and eligibility must ALWAYS be verified with the health plan.  Failure to obtain prior authorization for procedures or services not on this grid may result in denial of coverage; as a result, financial responsibility may be yours.  This grid applies to all members; it is intended to be a guide and does NOT guarantee coverage or payment.  Medical benefit plan language supersedes the general information provided on this grid.  The presence or absence of an item on this list does not define whether or not coverage or benefits exist for the service or procedure and CPT Code. Services that Do Not Require Authorization - Effective 2/13/2025 Page 1 of 10

SERVICE DESCRIPTION CPT/HCPCS CODE Abdominal Paracentesis 49082-49083 Administration of Chemotherapy* 51720, 52287, 96365-96368, 96372-96375, 96401-96411, 96413-96417, 96450, 96521 Annual depression screening G0444 Annual Physical Exams 99385-99387; 99395-99397 Aspiration and/or Injection of Joint 20600-20611 Basic Wound Care 12001-13153, 97602-97610, G0168 Biopsies: lip, external ear, tongue 40490, 41100, 41105, 69100 Brief emotional/behavioral assessment 96127, 96150-96152 B-12 Injections 96372, J3420 Canes E0100, E0105 Chemical Cauterization of Granulation Tissue 17250 Chest Tube/Catheter 32550-32552 Chronic Care Management Services 99439, 99453, 99454, 99457, 99458, 99487, 99489, 99490, G0506 Commodes E0163, E0165, E0167, E0168 Compression Devices E0650-E0652, E0655, E0660, E0665-E0669, E0671-E0673, E0675 CPAP (Continuous Positive Airway Pressure) Device and Supplies E0601, A4604, A7027-A7039, A7044-A7046 CPM (Continuous Passive Motion) Device; knee only E0935 Crutches and Crutch Substitute* E0110-E0117, E0153 Cystoscopy 52000 Debridement Procedures on the Skin In-office only (POS 11) 11042-11047 Debridement, Open Wound In-office only (POS 11) 97597-97598 Services that Do Not Require Authorization - Effective 2/13/2025 Page 2 of 10

SERVICE DESCRIPTION CPT/HCPCS CODE Decubitus Care Equipment* E0181, E0185, E0196 Destruction any method; malignant lesions 17260-17286 Destruction any method; premalignant lesions 17000-17004 Destruction any method; benign lesions (other than skin tags or cutaneous vascular proliferative lesions) 17110, 17111 Diabetic Foot Care, Basic (diabetic shoes not included) G0127, G0245-G0247, 11719-11721, 11055- 11057 Diabetes Outpatient Self-Management Training G0108, G0109 Diagnostic Anoscopies 46600, 45300 Dialysis Services (including out of area) 90935-90940, 90945-90947, 90951-90970, 90999, Q4081 Dressings A6010, A6011, A6021-A6025, A6154, A6196- A6199, A6203-A6224, A6228-A6248, A6250- A6262, A6266, A6402, A6403, A6410-A6412, A6441-A6457

DXA Scan 77080-77086 Ear Wax Removal 69209, 69210, G0268 ECG 93000-93010, 93040-93042 ECG/Holter Monitoring, up to 48 hours 93224-93227 Enteral and Parenteral Nutrition and Supplies* B4034-B4036, B4081-B4083, B4087, B4088, B4102-B4104, B4149, B4150, B4152-B4162, B4164, B4168, B4172, B4176, B4178, B4180, B4185, B4189, B4193, B4197. B4199, B4216, B4220, B4222, B4224, B5000, B5100, B5200, B9002, B9004, B9006, B9998, B9999 Evaluation and Monitoring of Cardiovascular Devices 93279-93298, 93724, G2066 Eye Exam with Photos 92250 Excision of Chalazion (Meibomian Cyst) 67800-67805 Services that Do Not Require Authorization - Effective 2/13/2025 Page 3 of 10

SERVICE DESCRIPTION CPT/HCPCS CODE External Cardiographic Recording (48 hours – 21 days) 93241 - 93248 Fine Needle Aspiration with and without Imaging Guidance 10004-10012, 10021 Finger Splinting 29130, Q4049 Foreign Body Removal 10120, 10121, 24200, 65205, 69200 Fracture Management (confirmed, non-surgical): Follow up X-ray, Initial & Follow up Office Visits, Splinting, Casting and Cast Removal 29000-29750 Ganglion Cyst Aspiration/Injection (non-guided) 20612 Gastric Suction Pump E2000 Glucose Monitoring by Subcutaneous Device (Physician fees only – actual device/monitor (K0553, K0554) requires prior authorization) 95249-95251 Hemodialysis Insertion, Repair/De-clotting, and/or Removal of Dialysis Catheter 36831-36833, 36860-36861, 36593, 36589- 36590, 36800-36821 HIV Testing All Home Visits by a PCP 99324-99337, G0179-G0180 Humidifiers/Compressors/Nebulizers E0561, E0562, E0565, E0570, E0572, E0574 Incision and Drainage 10060-10061, 10080-10081, 10140, 10160, 10180, 26010-26034, 46050 Incision/Excision of Thrombosed External Hemorrhoids 46320, 46083 Incontinence Supplies* A4310-A4316, A4320-A4322, A4326-A4328, A4330-A4338, A4340, A4344, A4346, A4349, A4351-A4358, A4360, A5102, A5105, A5112- A5114, A5120-A5122, A5126, A5131, A5200 Infusion Port-a-Cath, or Power-Ports (central line access catheters) including Insertion, Removal, Repair and Catheter Care 36595-36596, 36555-36571, 36575-36590 Ingrown Toenail Removal, Biopsy, Repair 11730, 11732, 11740, 11750, 11755, 11760, 11765 Services that Do Not Require Authorization - Effective 2/13/2025 Page 4 of 10

SERVICE DESCRIPTION CPT/HCPCS CODE Inhalation Treatments 94640, 94644-94645, 94664 Injection of Tendon Sheaths, Bursa and Trigger Points 20526-20553, 20600, 20605, 20610 In Office Injections: Toradol, Benadryl, Dexamethasone, Phenergan, Carbocaine, Depo-Medrol, Marcaine, betamethasone acetate/sodium phosphate, Kenalog, furosemide, midazolam, alteplase recombinant, bupivicaine J1885, J1200, J1100, J2550, J0670, J1030, J2930, J3490, J0702, J3301, J1940, J2250, J2997, S0020 INR Monitoring 93792-93793, G0250, 85610 Instillation Drug/Chemical by Chest Tube 32560-32562 Insulin Pump Supplies (Vendor: Mini Pharmacy) A4230 Intercostal Nerve Block 64420, 64421 Intraperitoneal Catheter Insertion and Removal 49418, 49422 Intrathoracic Placement Radiation Therapy Devices 32553 Irrigation of Bladder 51700 IV Hydration—Normal saline, D5W and/or LR 96360, 96361, J7030, J7040, J7050 Mammography and Breast Tomosynthesis 77061-77067, G0279 Manual Wheelchairs, Manual Wheelchair Accessories, and Wheelchair Cushions* E0951, E0958-E0961, E0971, E0973, E0974, E0978, E0980- E0982, E0990, E0992, E0994, E0995, E1015, E1017, E1020. E1028-E1030, E1050, E1060, E1070, E1083, E1084, E1087, E1088, E1092, E1093, E1100, E150, E1160, E1161, E1170-E1172, E1180, E1190, E1195, E1200, E1220-E1228, E1231-E1238, E1240, E1270, E1280, E1295-E1298, E2201-E2230, E2291-E2295, E2601-E2608, E2611-E2616, E2619- E2633, K0001-K0007, K0015, K0017- K0020, K0037-K0053, K0056, K0065, K0069- K0073, K0077, K0105, K0195 Marsupialization of Bartholin’s Cyst 56440 Services that Do Not Require Authorization - Effective 2/13/2025 Page 5 of 10

SERVICE DESCRIPTION CPT/HCPCS CODE Nasopharyngoscopy with Endoscope 92511 Measurement of post voiding residual urine and/or bladder capacity by ultrasound, non-imaging 51798 Medical Nutrition Therapy Services (Diagnosis of renal disease or diabetes ONLY) 97802-97804, G0270 Needle localization by X-Ray 77002 Negative Pressure Wound Therapy (Wound Vac) and Supplies E2402, A6550, A7000 Nitric Oxide Expired Gas Determination 95012 Non-invasive Vascular Studies: extremities 93922-93924 Occipital Nerve Block 64405 Office Visits (POS 11 only) 99202-99215 Ophthalmological Special Services Visual field exam, Biometry, Optical Coherence Tomography (OCT), Fundus photography 92083, 92132-92134, 92136, 92250 Ophthalmology Exam and Evaluation including determination of refractive state for purpose of prescribing glasses or contacts 92002-92014, Oral Phosphate Binders (Part B Drugs) J0601, J0602, J0603, J0607, J0615 Orthopedic Devices E0910-E0912, E0920, E0930, E0940-E0948 Orthotic: knee, shoulder, shoulder/elbow/wrist/hand, wrist/hand (off the shelf, prefabricated only) L1812, L1820, L1832, L1833, L1902, L3670, L3908, L3960 Osteopathic Manipulative Treatment (OMT) 98925-98929 Ostomy Pouches and Supplies* A4361-A4369, A4371-A4373, A4375-A4400, A4402, A4404-A4435, A5051-A5057, A5061- A5063, A5071-A5073, A5081-A5083, A5093 Outpatient PT/OT/ST— Initial Evaluation and 1 (one) Treatment (free standing facility only) 97161-97163, 97165-97167, 92521-92523 Services that Do Not Require Authorization - Effective 2/13/2025 Page 6 of 10

SERVICE DESCRIPTION CPT/HCPCS CODE Oxygen and Respiratory Equipment and Supplies A4614-A4626, A4628-A4629, A7001-A7018, E0424-E0444, E0466-E0480, E0600, E1353- E1355, E1372, E1390-E1392, K0738, K0739 Patient Lifts E0621, E0630, E0635 Percutaneous Drainage 75984, 75989 Pessary Fitting & Insertion 57160, A4562 Plain Film X-Ray (in-office or free-standing facility only) 70030-70160, 70190-70330, 70360-70370, 70380, 71045-71130, 72020-72120, 72170- 72190, 72200-72220, 73300-73030, 73050- 73080, 73090-73110, 731120-73140, 73501- 73523, 73560-73565, 73590-73660, 74018- 74022, 74210-74220, 76000, 76080-76098, 77074-77075 Pleural Aspiration and Drainage 32554-32557 Portable Infusion Pump – refill, maintenance, irrigation 96521-96523 PPD Tuberculosis Test 86580 Prostate Screenings G0102 Pulmonary/Respiratory Function Tests: Stress test, simple; diffusing capacity; plethysmography for lung volume; spirometry; respiratory flow volume workup 94010, 94060, 94618, 94375, 94726, 94729 Pulse Oximetry 94760, 94761 Removal of Foreign Substance and Infected/Devitalized Tissue 11000-11012 Routine Medicare-covered Vaccinations , 9065390658 (90654 is deleted from range)90660-90662, 90670, 90672-90674, 90682, 90685-90688, 90732, 90739, 90740, 90743, 90744, 90746, 90747, 90756, G0008- Services that Do Not Require Authorization - Effective 2/13/2025 Page 7 of 10

SERVICE DESCRIPTION CPT/HCPCS CODE G0010, Q2034-Q2039 Shave, Punch or Excisional Skin Biopsies 11102-11107, 11300-11313, 11400-11446 Skin Lesion removal; confirmed malignant 11600-11646 Smoking and Tobacco Cessation Counseling 99406-99407 Spinal Manipulation 98940, 98941, 98942 TENS (Transcutaneous Electrical Nerve Stimulation) device E0730, A4556-A4557, A4595 Tracheostomy Supplies and Speaking Valve A4605, A4608, A4481, A7501-A7509, A7520- A7527, L8501 Transfer Bench/Device E0705 Treatment of Genital Warts 56501, 56515, 57061, 57065, 54050-54065 Treatment of hidradenitis; excision and repair 11450-11471 Treatment of Lesions; injection 11900-11901 Ultrasound 76506, 76510-76529, 76536-76800, 76801- 76802, 76805-76819, 76830-76873, 76881- 76882, 76975, 76977 Ultrasound Guidance for Needle Placement and Vascular Access 76942, 76937 Urinary Catheterization (insertion/removal) 51701-51703, A4351, A4358 Vein Mapping for Fistula 93970, 93971 Walkers E0130, E0135, E0140-E0144, E0147-E0149, E0153-E0159 For OB/Gyn Specialists Only: In-Office GYN Procedures: Endometrial Biopsies, Colposcopies with Biopsy 58100, 58110, 58555, 58558, 57420-57421, 57452-57461, 56820, 56821, G0123-G0124, Q0091, Q0111 Services that Do Not Require Authorization - Effective 2/13/2025 Page 8 of 10

SERVICE DESCRIPTION CPT/HCPCS CODE For ENT Specialists Only: Control of Nosebleed, Nasal Endoscopy Dx, Nasal/Sinus Endoscopy Surg, Diagnostic Laryngoscopy, Ear Microscopy Examination, Basic Vestibular Evaluation, Spontaneous Nystagmus Test 30901-30903, 30905, 30906, 31231, 31237, 31238, 31505, 31575,92504, 92540, 92541 For ENT & Audiology Specialists Only: Tympanometry & Reflex Threshold, Pure Tone Audiometry Air, Audiometry Air and Bone, Speech Threshold Audiometry, Speech Audiometry Complete, Comprehensive Hearing Test, Tympanometry, Acoustic Reflex Threshold Test 92550, 92552, 92553, 92555, 92556, 92557, 92567, 92568 For PCP’s only: Office-based evaluation & management services; Medicare-covered preventive services All In-Office Laboratory Services: Collection of venous blood venipuncture, Urinalysis, non-automated without microscopy, Glucose, serum glucose monitoring device(s) cleared by the FDA specifically for home use, Heterophile antibodies— screening, Tuberculosis, intradermal, Urine pregnancy test, by visual color comparison methods, Infectious agent enzymatic activity other than virus (e.g., sialidase activity in vaginal fluid), Detection Infectious Agent by Immunoassay with Direct Optical Observation 36410, 36415, 81000-81003, 82962, 86308, 86580, 81025, 87905, 87804, 87807, 87808, 87809, 87880, U0001, U0002, 87635 Outpatient Mental Health/Behavioral Health Services Services must be provided by a: licensed psychiatrist or doctor, clinical psychologist, clinical social worker, clinical nurse specialist, nurse practitioner, physician assistant, or other Medicare-qualified mental health professional as allowed under applicable state laws All outpatient mental health counseling and treatment services including drug and alcohol abuse do not require prior authorization with the exception of the below services: • Trans Magnetic Stimulation (TMS) All Services that Do Not Require Authorization - Effective 2/13/2025 Page 9 of 10

SERVICE DESCRIPTION CPT/HCPCS CODE • Electro Convulsion Therapy (ECT) • Intensive Outpatient Treatment (IOP) • Partial Hospitalization (PHP) • Medication Assisted Treatment (MAT) Basic Prenatal Care All Chiropractic Services All East Valley Access Center All Emergency and Urgent Care Services All Family Planning and Sensitive Services All Hospice All In Network Laboratory Services Includes screening/testing for COVID-19 detection and antibodies All Language Assistance Programs/Interpreter Services All Sexually Transmitted Disease Services All Unique Labs (Homebound members ONLY) All Coverage is subject to medical necessity, based on CMS guidelines Coverage is subject to medical necessity and approval/authorization of drug ***Coverage is limited to the enrollee’s benefit plan and visit limitations Services that Do Not Require Authorization - Effective 2/13/2025 Page 10 of 10